Delhi

East Delhi

CC/501/2017

PUNEET WADHWA - Complainant(s)

Versus

APOLLO MUNICH - Opp.Party(s)

05 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 501/17

 

Shri Puneet Wadhawa

R/o D-1, Krishna Nagar

Delhi – 110 051                                                           ….Complainant

Vs.    

 

M/s. Apollo Munich Health Ins. Co. Ltd.

Through Authorized Signatory

2^nd, 3^rd Floor, ILBAS Centre

Plot No. 404-405

Udhyog Vihar, Phase – III

Gurgaon, Haryana – 122 016                                          …Opponents

 

 

Date of Institution: 11.12.2017

Judgement Reserved on: 05.02.2020

Judgement Passed on: 18.02.2020

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Shri Puneet Wadhawa against    M/s. Apollo Munich Health Insurance Co. Ltd. (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.       The facts in brief are that the complainant Shri Puneet Wadhawa was having policy from M/s. Apollo Munich Health Insurance Co. Ltd.    (OP) vide policy no. 1100105/11121/1000152317-06 and was paying the premium without fail till his treatment.  He renewed the said policy from 13.01.2017 to 12.01.2018 and during this period, he continuously paid the policy premium.  On 26.08.2017, he met with an accident and was admitted in Max Super Specialty Hospital where he got the treatment and spent more than Rs. 20,00,000/- on his treatment and medicines. 

He intimated to OP and made a demand of his claim for the injury suffered by him.  However, they refused to pay the claim through their letter of dated 26.10.2017 stating that “the submitted claim is for treatment of multiple fracture, which is a consequences/complication of alcohol/drug intake.  Treatment related to alcohol abuse/substance abuse is excluded in the policy, hence we regret to inform you that your claim has been repudiated under Section V(C)(v) of the policy”.  Thus, they repudiated the claim due to non-disclosure and concealment of facts under Section V(C)(v) of the policy terms and conditions. 

It has been stated that at the time of accident, the complainant was not under the influence of alcohol/drugs and even the hospital have nowhere mentioned/disclosed that the complainant was under the influence of alcohol/drugs at the time of accident.   The insurance company have not given any satisfactory answer to the complainant. 

It has further been stated that on account of the dereliction of duty and negligence on the part of OP, the complainant have suffered loss and injury due to deprivation, harassment, mental agony and loss of reputation for which he was entitled for compensation of Rs. 2,00,000/- alongwith claim of Rs. 15,66,250/- (basic sum insured Rs. 10,00,000/- plus multiplier benefit of Rs. 5,66,250/-) along with interest.  He has prayed for directions to OP to pay the policy amount of Rs. 15,66,250/- alongwith interest; compensation of Rs. 2,00,000/- on account of mental pain and agony and Rs. 22,000/- towards litigation expenses.        

3.       In the reply filed on behalf of M/s. Apollo Munich Health Insurance Co. Ltd. (OP), they have taken various pleas, however, the material one is extracted.  They have stated that the cashless was enhanced from          Rs. 3,00,000/- to Rs. 4,50,000/- with the condition that they will not make the payment in the event of the facts presented by the hospital/insured during pre-authorization were found to be incorrect/revised.  They sought reply from the hospital and after getting the reply, they noted that the complainant was under the influence of alcohol at the time of accident.  Thus, they denied the cashless. 

On submission of the claim for reimbursement on 23.10.2017 amounting to Rs. 20,82,633/-, they repudiated the claim through their letter of dated 27.10.2017 stating that “The submitted claim is for treatment of Multiple fracture which is a consequence/complication of Alcohol/drug intake.  Treatment related to alcohol abuse/substance abuse is excluded in the policy.  Hence, we regret to inform you that your claim has been Repudiated under Section V(C)(v) of the policy.”   

They have further made reference to Section 4 of the insurance policy which deals with special terms and conditions of the insurance.  Clause ‘C’ deals with General Exclusions.  Thus, they have stated that as per exclusion clauses, the claim was not payable under Section 5(c)(v).  They have denied other facts also.   

4.       Complainant have filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.       In support of its case, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been  stated in the complaint.  He has also got exhibited copy of renewal kit from 13.01.2017 to 12.01.2018 (Ex.PW-1/A), copy of claim form (Ex.PW-1/B), copy of bills medical summary report and claim rejection letter (Ex.PW-1/C colly.) and copy of statements dated 27.08.2017 (Ex.PW-1/D). 

          In defence, OP have examined Ms. Deepti Rustagi, Vice President-Legal & Chief Compliance Officer of OP, who have also deposed on affidavit.   She has also narrated the facts which have been stated in the WS.  She has got exhibited copy of Authority Letter (Ex.R-1), copy of proposal form bearing no. 1100944497 dated 28.12.2011 (Ex.R-2), copy of easy health standard policy wordings and change request form and optima restore floater policy and policy wordings (Ex.R-3 & 4), pre-authorization form (Ex.R-5), query letter (Ex.R-6), cashless denial letter (Ex.R-7), cashless authorization letters (Ex.R-8), investigation report (Ex.R-9), medical documents showing alcoholism and clearly mentioned that fall from height under the alcohol influence (Ex.R-10), cashless denial letter     (Ex.R-11) and claim form dated 23.10.2017 (Ex.R-12).   

6.       We have heard Ld. Counsel for the complainant and have perused the written arguments filed on behalf of OP as the Counsel for OP did not appear to argue.

In the written arguments filed on behalf of OP, they have taken the plea that the claim was not payable as the complainant had suffered injury as a result of being under the influence of alcohol at the time of incident/accident and any accident which was consequence of alcohol was excluded in the policy.

          On the other hand, Ld. Counsel for the complainant have argued that OP have filed fabricated/forged documents i.e. case summary with connivance of Max Hospital that the complainant was under alcohol influence at the time of accident, but hospital/OP failed to mention how much quantity of the alcohol was in the blood and also failed to file any report which shows that the complainant was under the influence of alcohol at the time of accident.

To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the evidence of the complainant as well as of OP and the documents placed on record by both the parties.  Firstly, the testimony of Ms. Deepti Rustagi, Vice President-Legal of OP alongwith the documents got exhibited in her testimony is perused.  In her testimony, she has got exhibited copy of medical documents showing alcoholism as Ex.R-10 (wrongly exhibited though it should be R-12).  This document is a case summary showing that “patient was admitted in Max Hospital with alleged history of fall from height under alcohol influence”.  Except this document, no other document has been placed on record to substantiate the fact that the complainant was under alcohol influence.

On the other hand, complainant have got exhibited in his testimony the copy of bill/medical summary report and rejection letter as Ex.PW-1/C (colly.).  Since the discharge summary which was got exhibited in the testimony of the complainant was not legible, the complainant was directed to file the original discharge summary which he did so.  If the discharge summary is perused, it is noticed that in the discharge summary when the complainant was admitted in the hospital on 26.08.2017, under the head “Diagnosis”, there is nothing to suggest that the complainant was admitted in the hospital under the influence of alcohol.

Even if the documents case summary [Ex.R-10 (wrongly exhibited though it should be R-12)] is looked into, it has to be seen as to whether this document was sufficient to base rejection of the claim of the complainant.  For this, firstly, a look has to be made to the terms and conditions of the policy.  Section 5(c) of the policy has been under the head “General Exclusion”.  Section 5(c)(iv) is in respect of medical exclusions.  Under this clause, it has been stated that “Abuse or the consequences of abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.“

Under this clauses, use of alcohol has been made a ground for non-payment of claim of the insured person.  No doubt, this clause is an exclusion clause for non-payment of claim, but the plea which has been taken on behalf of complainant has been that even if the arguments of Ld. Counsel for insurance company (OP) is taken to be correct one, the insurance company have to make out a case for exclusion on the ground that the incident/accident was the consequence of use of alcohol. 

He has further argued that no scientific evidence has been placed on record to show how much quantity of alcohol was found in the blood of the complainant to affect his state of mind.  He has further argued that mere reference as there was alcohol does not amount to the fact that the complainant had the inability to judge the consequences. 

Admittedly, in the case summary (Ex.R-12) on which Ld. Counsel for OP have relied upon, merely uses the word “Fall from height under alcohol influence”.  Here, it would be relevant to have reference to the medical book titled “The Essential of Forensic Medicine and Toxicology” by Dr. Narayan Reddy where it has been stated that the percentage of alcohol to determine under the influence of alcohol, the level is 80-100mg%.

In the present case, no scientific report has been filed to show as to what was the percentage of alcohol level in the blood of the complainant.  Not only that, no nexus has been established with the presence of alcohol and the incident which has happened.  In the absence of any scientific report, mere presence of alcohol in the body of the complainant does not make out a case for repudiation of claim under the Exclusion clause.  Thus, the repudiation of the claim by the insurance company was not justified. 

In view of the above, we hereby order that M/s. Apollo Munich Health Insurance Co. Ltd. (OP) shall pay to the complainant the claim amount on non-standard basis i.e. 75% of the sum insured. 

This order be complied within a period of 60 days.  If not complied, the awarded amount shall carry 6% interest from the date of receipt of order.        

Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

 

 

(DR. P.N. TIWARI)                                               (HARPREET KAUR CHARYA)

       Member                                                                             Member 

 

(SUKHDEV SINGH)

                   President